Hypergranulation tissue (proud flesh or granuloma)

The following is an edited version of what I originally added to this blog as a post.

Until you are able to get the granulation to abate, you must keep the tube immobile. NO weight on the stoma, no wiggling during the day except for when you’re using the tube. Turn it once per day, or as instructed by your doctor. I go into this more towards the end of this page, but wanted to lead with this.

During use, try placing a rolled wash cloth under the side the tube gets pulled toward

Don’t keep removing the overgranulation. Its okay to get rid of what you can see with silver nitrate, Granulotion, or another astringent/caustic topical. As soon as the granulation you can see is gone, or greatly diminished, switch to an anti inflammatory such as triamcinolone.

Don’t apply topicals that are used for wound debridement unless directed by your medical provider. That means steer clear of manuka honey and products that contain caster oil.

I dealt with overgranulation for the first several years that I had a g tube. I no longer have it. Written below is what I have learned through research, and personal experience.

The surgically created tunnel that forms around a gastrostomy tubewhere it connects to a port on the outside of the body is called a stoma. And, that stoma, for many people, can have long term problems with the formation of granulation tissue overgrowth. The old terminology for this is proud flesh.

Even though we may not consider a feeding tube that is surgically placed to be a wound, our body does. It cannot differentiate between an accidental wound, and one that has been intentionally created. And when that wound healing is interrupted for various reasons, a tube feeder can find themselves dealing with an ongoing, and seemingly endless headache of trying to fix the problem. And usually this means without much help from medical providers.

If you have swollen, red, lumpy, moist tissue or flesh around the stoma site, then it is most likely hypergranulation tissue. This tissue can a exude yellow, sticky pus. It may be painful, bleed easy, and prevent your stoma from healing the way it should. Hypergranulation can occur for no apparent reason (friction, moisture or irritation may be contributing factors), especially during the first three months after the tube has been placed.

There is a great difference between chronic wound healing and acute wound healing, and they are not interchangeable. For some, our body identifies the stoma to be a chronic wound, and complete healing does not take place, sometimes indefinitely.

The healing process associated with an acute wound is a dynamic one which can be divided into three phases (Dealey 2007): • Inflammation • Proliferation • Maturation

If certain triggers take place, and the stoma is subjected to prolonged inflammation caused by infection or foreign body irritant (yes, that foreign body is the feeding tube) what happens is the stoma (wound) can get ‘stuck’ in the healing cycle, the wound dynamics will change and the wound will not continue to fully heal.

The following are excerpts from a UK publication Wound Care Today. I know its kind of dry and uses a lot of medical terminology, and you may be tempted to not bother reading it all ; but, make the effort, as it is a very good explanation of the whats and whys of granulation tissue formation.

Granulation tissue is an intermediary replacement for normal dermis, which matures into a scar during the re-modelling phase of wound healing (Johnson, 2007). Granulation incorporates a dense network of blood vessels – newly growing capillaries (angiogenesis) – with an irregular upper layer created by the capillaries looping together on the wound surface. This gives granulation the appearance of red lumps (or granules) within the normal paler pink matrix, although despite this appearance, granulation does not bleed easily (Dowsett, 2002). Granulation tissue demonstrates an elevated cellular density incorporating fibroblasts and macrophages, as well as randomly organised collagen fibres (Ovington and Schultz, 2004).

The presence of granulation tissue in the wound is a sign that healing is taking place and this new tissue will protect the wound from bacterial colonisation since it is resistant to infection (Dealey, 1999; Dunsford, 1999; Collins et al, 2002). Many factors can delay wound healing (Hampton and Collins, 2003) and a lack, or an over-proliferation, of granulation tissue may delay healing and lead to a chronic wound… When granulation ‘over grows’ beyond the surface of the wound, this is known as overgranulation, also referred to as hypergranulation, exuberant granulation, hyperplasia of granulation, hypertrophic granulation or ‘proud’ flesh. It is usually present in wounds healing by secondary intention and is clinically recognised by a friable red, often shiny and soft appearance, which is raised above the level of the surrounding skin (Figure 3) (Johnson, 2007). The tissue can be healthy (Figure 4) or unhealthy (Figure 5) (Harris and Rolstad, 1994)…. However, whether or not the overgranulation is regarded as healthy or unhealthy, the wound generally will not heal when the tissue is ‘proud’ of the wound because epithelial tissue will be impeded from migrating across the wound’s surface and contraction halted at the edge of the swelling…

The exact aetiology of overgranulation is unknown. The literature often links infection with overgranulation, but it is not clear which occurs first.

Vuolo (2010) suggests there are three types of overgranulation (see Table 1):

Type 1: inflammatory with excessive exudate due to continued minor trauma or friction from mobility

Type 3: cellular imbalance – an imbalance between collagen synthesis and degradation due to the patient’s pathology.

Although I can speak only from my own experience, and from what I have read, I believe that for the most part, those of us with feeding tubes who develop a problem with granulation tissue, have this problem due to Type 1 (above). I think it can also be for more than one reason, so determining the root of the problem is not always clear-cut. That may also be why some people will swear by one topical treatment, while another won’t find it effective at all.

It doesn’t have to be anything overly severe to keep that granulation formation process perpetuating. For example, it doesn’t have to be a major infection, just a little bit of a fungal infection due to the moist environment; or frequent–even if slight– movement of the feeding tube. Maybe skin around the tube gets stretched during daily activities, or too much pressure is placed on those newly formed blood vessels due to lifting something heavy, (grocery bags) or moving something heavy around(vacuum cleaner) .

After dealing with granulation tissue for four years, and finally getting rid of it for a period of months, having it recur, and then getting it to go again, I’ve finally figured out what works for me.

Friction is the ENEMY! Keep the peg tube completely immobile except for daily turning, and when cleaning skin under the button or flange.

No matter what topical product you are applying, until the cause is addressed and corrected, that tissue will come back.

For example, silver nitrate sticks work the very fastest. It will make that tissue shrivel almost instantaneously. This is because it is very caustic and it chemically cauterizes what it touches. But, unless the reason for the hypergranulation formation has been addressed, it will come right back with a vengeance.

Astringents are mild caustics, and they work slower, but with the same results. Alum is an example of a mild caustic (astringent). It is very gritty in the pickling spice form we find on our grocer’s shelf. Granulotion contains a micronized version of alum. With repeated application, this has the same effect as the silver nitrate sticks, just at a slower pace.

Topical steroid application will get rid of it fairly fast, but only while you’re using it. Steroids work by reducing and eliminating inflammation, regardless of what is causing the inflammation. It is a painless way to treat granuloma, and can be safely used on a regular daily basis for up to three months.

Steroids have several strength classifications, hydrocortisone is the mildest, and will not be effective. A class 4, mid strength, such as Kenalog (generic is Triamcinolone acetonide ) is what is needed. And, the 1% works a lot faster than the .025%

Using a cream such as triamcinolone for a few weeks will make the problem go away, or mostly go away. But, it, like the other topicals listed above, they do not fix what is causing the problem. Before you taper off using it, you absolutely need to try to figure out what is causing this cycle of overgranulation tissue to be taking place, and take steps to fix that. Because, when hypergranulation occurs, it is a way of the body saying, hey, I’m no longer an acute wound in the normal healing process, the body has decided it has a chronic wound, and the healing process has been interrupted indefinitely.

Now, if the overgranulation has sprung up in response to inflammation from an infection (either bacterial or fungal), and that infection is completely cleared up by treatment with either an antibiotic or antifungal, then, yes, you might be rid of it for good. Odds are, though, that it is a combination of factors causing it, and so you need to examine all possibilities for what is the main perpetrator,

In retrospect, the issue is not so much how to get rid of already formed granulation, the issue is finding the root cause of its formation and breaking the cycle.

In the first weeks after I got my tube (the long dangler) I had a fierce problem with overgranulation. I was unable to tape it due to a tape adhesive allergy. (I have since found a tape I can use, more about that below).

The problem was so bad, that my doctor opted to place a low profile “button” sooner than originally planned. This helped a LOT as there was less weight and less movement because I no longer had a tube hanging and moving around.

But, I was not free from overgranulation.

When I finally caught a break was for the period of a few months when I had a different button type peg tube other than the more well known brands (i.e. the Mic-key and AMT Mini one) The Corflo cuBBy is different in that it has a unique flower petal design, which means it sits up a bit from the skin surface on little feet –the “flower petals”. The feet make the button very stable, it doesn’t move nearly as much as a Mic-key or Mini one. (See image below) It was during this time, while I had the cuBBY that I finally was rid of any sign of granulation tissue. And, allowing airflow to my skin, as it is just tiny bit elevated, put the kibosh on fungal infection that tended to form on my skin surrounding my stoma in the past.

Corflo cuBBy low profile

The photo directly above is a picture I took after I’d had it for a while, and was still in the process of healing.

The only drawback that I found to using this type of feeding tube, is that because of those awesome feet, it is a bit harder to get under it to clean around the stoma.

It was not an overnight thing – not even a couple of weeks–but, eventually I began to have less “play” in the button and the perimeter of stoma at skin surface were “firmer”.

After a couple of months, I had no bloody streaks in the secretions, no greenish secretions, and very very minimal secretions at all. Any exudate was a pale yellow, almost clear. I had no pain. I had no hypergranulation at all

About the same time as I got the cuBBy I also started using a product called Wonder DT Lotion. Its an underground cult type favorite for those with ALS, and a helpful member of an online forum told me about it. This “lotion” is very thin, about the consistency of milk, and because it is so runny, it can go down into the stoma a bit, whereas all of the other products I’d used are thicker, and tend to stay mostly on the surface. It also does not burn at all, its not caustic, and so I didn’t have to protect the rest of my skin from it when applying it. I use it faithfully twice a day, every day.

I believe it helps in maintaining a healthy stoma, due to its antimicrobial and anti inflammatory properties, it creates an environment that is not welcoming to many of the triggers for overgranulation.

For me, it was the friction factor that was the main culprit in triggering the granulation tissue formation cycle, but the near constant mild fungal infections certainly played a role.

Once I was finally rid of the granulation tissue, things were going swimmingly until the anti-reflux valve on my cuBBy broke, and my doctor could not get me that same model to replace it with, as the hospital he uses contracts with the other manufacturers. And so I was back to having a Mic-key instead of the cuBBy.

It didn’t happen right away, but gradually, within two months, the granulation tissue was forming once again.

I believe, had I been able to replace the malfunctioning cuBBy with another cuBBy, or even if it had lasted a few months longer, that perhaps my stoma would not have reproduced the granulation tissue again. Even though there was none to be seen that day my doctor and I were looking inside of it during the peg swap, we did note two or three tiny red dots, and they were probably what produced the regrowth after getting the Mic-key.

As I was still using the Wonder DT Lotion, the only thing that had changed was the type of button device. As the big difference in buttons was the stability factor, and I was pretty much stuck with the Mic-key at that point, I was determined to find a way to stabilize it.

That was when I stumbled across HY tape. Finally a tape that I was not in the least allergic to! It was the turning point in getting the overgranulation to leave again, because I was able to tape my button so it did not move at all.

Once I found a way to keep that peg tube from moving, the granulation tissue once again abated.

So, if you have a long dangler, find out if you can shorten it. (that funnel port at the end does come off if you pull it hard) Lessening the weight of the tube helps a lot.

Tape your device securely. All day, all night, every day and night. Turn it when you clean it (if you have the type you’re supposed to turn) but beyond that, it shouldn’t move.

Keep the stoma clean, but don’t use harsh cleansers or topicals on it.

As irritation is definitely a factor in causing granulation tissue to hang around, don’t irritate it! Don’t use peroxide or alcohol. Don’t use anything other than plain water or a baby wash when cleaning it daily. Smith and Nephew makes a Personal Cleanser that is ph corrected, and it is handy as it is in a spray (spritz type) bottle.

The bottom line is keep the area clean as possible. Just do it gently.

Keep it dry

Stomas can easily develop fungal infections as the area tends to stay moist due to secretions.

I personally use cloth pads. I use them for several reasons, first because until very recently I knew I couldn’t tape a gauze sponge into place as I couldn’t use tape. But, as importantly as that–or even more so, really– is I don’t want to “look” sick. I don’t need a daily reminder that something is wrong with me by seeing a bandage there.

A pretty colorful tube pad looks a heck of a lot less “patient like” . They can be washed and reused over and over, they add to stability, and they allow the skin to breathe a bit. As I’ve always been a matching bra and panty sets kind of gal, I’ve gone so far as to try to at least color coordinate my tube pad to the rest of my underthings. Why not doll her up a little bit? She does a lot for me, as in allowing me to get needed nourishment!

You can purchase peg tube pads online at a vast number of eBay and Etsy shops.

OVER THE LONG HAUL

The collagen that has been laid down during the granulation period is replaced by stronger collagen, while the tissue beneath the scar, and the scar itself, will continue to remodel for up to two years! Therefore, even though you may think yourself free of any hypergranulation, next thing you know, bam! it rears its ugly head again.

I have added a page that describes how to maintain a healthy stoma, once it is achieved; but first, follow the drop down menu from this tab, to see more information on how to tape a tube, and topical treatments.